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WTF?

It’s good to see Nils’ post about the recent UK cryonics ruling getting shared around quite a bit – so it should. I thought I’d throw in my own voice, too.

About 18 months ago, Imogen Jones and I wrote a paper musing on some of the ethical and legal dimensions of Christopher Priest’s The Prestige. One dimension of this was a look at the legal status of the bodies produced as a result of the “magic” trick – in particular, the haziness of whether they were alive or dead; the law doesn’t have any space for a third state. The paper was something of a jeu d’esprit, written to serve a particular function in a Festschrift for Margot Brazier. If I say so myself, I think it’s a pretty good paper – but it’s also meant to be fun, and is clearly rather less serious than most ethico-legal scholarship (or anything else in the book, for that matter).

Not quite “Cold Lazarus”, but close enough…

So it’s a bit of a surprise to see relevantly similar themes popping up in the news. If we’re freezing people in the hope of curing terminal illness in the future, what’s the status of the bodies in the meantime (especially if the death certificate has been signed)? There’s a load of questions that we might want to ask before we get too carried away with embracing cryonics.

Right from the start, there’s a question about plausibility. For the sake of what follows, I’m going to treat “freezing” as including the process of defrosting people successfully as well, unless the context makes it clear that I mean something else. Now, that said, the (moral) reasons to freeze people rely on the plausibility of the technology. If the technology is not plausible, we have no reason to make use of it. It wouldn’t follow from that that using it’d be wrong – but since the default is not to act in that way, it’s positive reasons that we need, rather than negative ones. Neither could we really rely on the thought that we could cryopreserve someone in the hope that the freezing-and-thawing process becomes more plausible in future, because we’d have no reason to think that we’d chosen the right version of the technology. We can only cryopreserve a person once: what if we’ve chosen the wrong technique? How would we choose the best from an indefinitely large number of what we can at best treat as currently-implausible ones?

So how plausible is it to put a body on ice, then revive it many years later? It’s been pointed out by some that we currently do preserve embryos without apparent ill-effect, with the implication that there’s no reason in principle why more developed humans couldn’t be frozen successfully. However, whole humans are a wee bit more complex than embryos; it’s not at all clear that we can extrapolate from balls of a few cells to entire humans. Even the admittedly limited experimental evidence that it’s possible to freeze whole organs won’t show us that, since we’re systems of organs. One can accept that an organ is a system, too; but all that means is that we’re systems of systems – so we’ve squared the complexity. And, of course, the timescales being considered here are tiny compared with the kind of timescales envisaged in cryonic fantasies. more…

“And so that brings us neatly to the last item on the agenda: passport checks for pregnant women who want a checkup. The thing is, you see, that it turns out that we’ve been providing obstetric care to some women who aren’t actually UK citizens. And, clearly, that has to stop.”
“To stop?”
“Well, maybe not stop. But you know what I mean. We can’t go providing treatment to anyone who comes knocking at the door! Why, we’d have a queue from here to Timbuktu, not to mention the cost!”
“Oh, quite. No, I quite agree that we can’t be the world’s supplier of healthcare.”
“No. So that’s settled, then. No more obstetric services to women who can’t demonstrate their eligibility.”
“Hmmmm.”
“You don’t look convinced. What’s the problem? These women aren’t eligible.”
“Well, no. But… well, look. Remember when Dr Smith retired, and when Dr Jones got that transfer to work in the Inner Hebrides?”
“All too well. Two great losses to the Trust. What’s your point?”
“Well, I seem to remember that we pooled together to buy them nice leaving presents.”
“We did. It was the least we could do.”
“I agree. But, you see, the thing is, they weren’t actually entitled to them. If you see what I mean.”
“I’m not sure I follow.”
“No. Well, you see, the thing is, we bought them those presents, and gave them to them, because it’s the decent thing to do. There’s no rule that says that we have to buy them. They wouldn’t have been wronged if we hadn’t.”
“Yeeeeeeessssss… I mean, no. But yes.”
“But we gave them the presents anyway. Because the rules set out what’s minimially decent. Not an upper limit.”
“Yeeeeeesssss…”
“Well, you see, I was just wondering: might the same apply in other contexts? Allowing for the obvious differences, of course.”
“You’re losing me again.”
“I thought I might be. Well, you see, it’s like this. We’ve been providing treatment to pregnant women without paying attention to whether they’re entitled by the strict letter of the law. And that law specifies who is entitled to treatment. But that doesn’t necessarily impose any exclusions. You see, I wonder if by getting bogged down in the rules, we might… um…”
“Might what?”
“Well, you see, the thing is…”
“Go on…”
“Look: we might end up looking like utter shits.”

This is a bit of a strange post, not least because it involves citing sources – a blog post, and a whole blog -that have since been taken down from the net, for reasons that will become clear. It’s also going to involve a pair of fairly hefty quotations, largely because it’s the absence of a source that motivates this post – which means I can’t simply tell you to follow the links. It has to do with an apparent case of a surgeon deliberately causing a serious injury to a patient in the name of teaching, and with deceptions, and with apologies for those deceptions.

It’s also a very long post, even by my prolix standards.

OK: so, as quoted by Orac on his Respectful Insolence blog, here’s the case that gets the story going. It was originally recounted by someone calling themselves “Hope Amantine”, and was cross-posted atKevinMD.com, which bills itself as “social media’s leading physician voice”, is written by someone called Kevin Pho, and is a part a site called MedPage Today. This means that Orac’s version is at least third-hand; but I can’t do better than that, for reasons that will become clear. That’s a pain, but I’m going to have to take things on good faith – which, given what comes later, is perhaps asking for trouble. Either way, here’s the story:

So here I was, handling the plane (the layer, or space) around the IVC [inferior vena cava] with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow. I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me. This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole. No problem.

All he said was, “Good job.” And we proceeded to complete the case uneventfully.

[…]

Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.

[…]

So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

The excisions are mine – they’re where Orac makes a comment. However, there’s one more part that’s important – and this is now in Orac’s voice:

The reaction to Dr. Amantine’s post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:

Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.

Orac calls BS on this, and I’m tempted to do likewise; but I’ll put that to one side for now. I’ll also note that I can’t check the flow of the original post, because it no longer exists. Indeed, Hope Amantine’s whole blog would seem to have been taken down. In the meantime, other blogs and pages also picked up the story from KevinMD: PZ Myers noted it on Pharyngula, Janet Stemwedel commented in a piece on Forbes‘ site, and I’m sure there were more. This is noteworthy, because, as I said, the OP has now gone. If you want to read it, you’ll have to go to where it was cross-posted or quoted (which makes this whole thing rather like a game of Chinese Whispers).

Indeed, not only has the OP gone: the KevinMD post has also gone. Where it was, there’s this message: more…

A few weeks (months?) ago, I got a call from Cosmopolitan to ask if I’d talk about home-testing kits for genetics – stuff like what 23andMe offers. We talked, and I like to think that I said something useful… and promptly forgot all about it, until just now, when the University of Manchester press office sent me a link to this: a story about HIV self-testing kits in the UK.

It’s a piece that quotes me. It quotes me from that interview I did about genetic – genetic! – tests:

Iain Brassington, Healthcare Ethics professor at the University of Manchester told Cosmo Body:

“People invest a lot in genetic information and it could have a serious psychological impact. Someone could feel anxious, distraught, even suicidal if they find out they are carrying a gene associated with particular diseases.”

Can you see the problem here?

Apart from the fact that I’m not, and am unlikely soon to be, a Professor, I mean?

OK: for clarity’s sake (and just in case there are any Cosmo readers who’ve drifted here): genetic tests and HIV tests are VERY DIFFERENT THINGS, and raise CORRESPONDINGLY DIFFERENT PROBLEMS. I don’t think that HIV is a genetic condition. Only idiots think that. Some of the problems with one might well be problems with the other. But we can’t leap between the two so easily. I don’t know what I think about home HIV tests; I’ve not thought about them much, and noone’s asked me to have an opionion on them yet. THIS QUOTATION MAKES ME LOOK LIKE AN IDIOT.

Also, they put words in my mouth. I can’t remember what I said, but I doubt it’d’ve been anything as fatuous as “Someone could feel anxious, distraught, even suicidal if they find out they are carrying a gene associated with particular diseases.” That’s simply not the kind of thing I say.

Yes, I’m posting here shamelessly, because I don’t want that particular piece to appear if people Google me without some kind of balancing act. And I’m posting a screengrab just below the fold for posterity’s sake, just in case Cosmo deletes the page.

There’s a part of me that recognises this story as having been in the news before – but I don’t think I’ve written on it, so here we go. It’s from the Telegraph, under the headline “Son Challenges Belgian Law after Mother’s ‘Mercy Killing'” – which is a reasonably pithy summation of what’s at issue. A man, Tom Mortier, is attempting to bring a case before the European Court of Human Rights that would have Belgian laws on euthanasia scrutinised and – he hopes – declared contrary to the ECHR:

A Belgian man is going to the European Court of Human Rights after his depressed mother was killed by lethal injection under the country’s liberal euthanasia laws. […]

Mr Mortier is trying to take his mother’s case to the Strasbourg court under the “right to life” legislation in the European Convention of Human Rights. He hopes, at the very least, to trigger some debate in his country, and secure greater oversight in the way the existing rules are applied.

OK – so it’s not clear whether he’s actually got the Court to agree to hear his case (which is what “going to the ECtHR” suggests in ordinary usage), or whether he’s still attempting to get it to agree to hear it. If it’s the latter, then he might be going to the ECtHR in the sense of being physically present – but that’s not going to achieve much. The Telegraph isn’t clear on this. Oh, well. But is there anything of substance to his case? It might have substance and still fail, of course – it’s perfectly possible for a court to say that they can see a person’s point, but that it’s not sufficiently powerful; but if it has no substance, then it ought to fail.

Based on the Telegraph‘s report, it seems that there really isn’t much substance to it. This is not to say that there’s none – but there’s not much. And, as we’ll see, it’s a bit strange in some ways. more…

It turns out that the version of the Medical Innovation Bill about which I wrote this morning isn’t the most recent: the most recent version is available here. Naïvely, I’d assumed that the government would make sure the latest version was the easiest to find. Silly me.

Here’s the updated version of §1(3): it says that the process of deciding whether to use an unorthodox treatment

(c) consideration of any opinions or requests expressed by or on behalf of the patient;

(d) obtaining any consents required by law; and

(e) consideration of all matters that appear to the doctor to be reasonably necessary to be considered in order to reach a clinical judgment, including assessment and comparison of the actual or probable risks and consequences of different treatments.

So it is a bit better – it seems to take out the explicit “ask your mates” line.

However, it still doesn’t say how medics ought to weigh these criteria, or what counts as an appropriately qualified colleague. So, on the face of it, our homeopath-oncologist could go to a “qualified” homeopath. Or he could go to an oncologist, get told he’s a nutter, make a mental note of that, and decide that that’s quite enough consultation and that he’s still happy to try homeopathy anyway.

So it’s still a crappy piece of legislation. And it still enjoys government support. Which does, I suppose, give me an excuse to post this:

Look, I know that Twitter really isn’t the place for nuanced debate. But, by that token, everyone else should realise that as well – especially intellectual superstars. So how, then, to explain Richard Dawkins’ spectacular foot-in-mouth moment earlier today? It started off reasonably enough, with him tweeting about Catholicism’s stance on abortion and providing a link to this piece by Jerry Coyne in the New Republic; lots of people are going to agree with both Coyne and Dawkins, and lots to disagree, but we should expect that. The tweet got a couple of replies. I can’t be bothered transcribing them, but here’s a screenshot; you should be able to click to enbiggen it.

So far so good. Dawkins’ reply is about as good a version of the sentience argument that you could cram into 140 characters; and InYourFaceNewYorker’s point articulates a problem faced by any number of women who are carrying a child with a disability of some kind. (Well, by any number of parents, I suppose, except that it’s women who hold the moral trump here simply by dint of being the one carrying it. Fathers could agonise about the best thing to do, too; it’s just that they don’t get to make the final decision. Oh, you know what I mean.) Where you stand on abortion doesn’t preclude recognising that it’s a genuine moral dilemma for many people, and a that there are respectable arguments and proponents of those arguments on both sides – by which I mean that people on either side should be able to recognise that their opponents are at the very least worth the effort of an argument. InYourFaceNewYorker goes on to articulate some of the aspects of the debate that make it so emotive and so intellectually rich:

Yes, yes: it’s tedious and internecine, but it’s almost a year since I had a pop at Kevin Yuill’s book on assisted dying; how about an update? Well, conveniently, there’s this, in which he tries “to convince my fellow liberal minded atheists to reconsider their support for legalized assisted dying”. OK, then. First up, this isn’t a pro-legalisation post: I’m much more interested in looking at the arguments presented in their own terms. I think they’re bad; but that is to do with their form rather than their content. Indeed, one of Yuill’s opening moves is something to which I’m sympathetic: in respect of Lord Falconer’s latest Bill to legalise assisted dying, he points out that

the chief sponsoring agency (Dignity in Dying) lamely differentiates between the dying (those with six months or less to live) and those with more time.

If the latter ingest poison in a room by themselves – well, that’s suicide. But if those with less than six months take poison with the intent to end their lives, that is not suicide at all but <ahem> assisted dying. Nope, me neither.

I agree that the six-month time limit is arbitrary, and probably morally indefensible. But…

It’s funny how things come together sometimes. A few months ago, I mentioned a slightly strange JAMA paper that suggested that non-compliance with treatment regimes should be treated as a treatable condition in its own right. The subtext there was fairly clear: that there’s potential scope for what we might term “psychiatric mission-creep”, whereby behaviour gets seen as pathological just if it’s undesirable and can be changed with drugs. I was reminded of this by a couple of things I found last weekend.

I was avoiding work by pootling away on the internet, and stumbled across a couple of things. This – an article about American politics that notes the use of psychiatry as a means of social control – was one of them:

[In 1980] an increasingly authoritarian American Psychiatric Association added to their diagnostic bible (then the DSM-III) disruptive mental disorders for children and teenagers such as the increasingly popular “oppositional defiant disorder” (ODD). The official symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules,” “often argues with adults,” and “often deliberately does things to annoy other people.”

Many of America’s greatest activists including Saul Alinsky […] would today certainly be diagnosed with ODD and other disruptive disorders. Recalling his childhood, Alinsky said, “I never thought of walking on the grass until I saw a sign saying ‘Keep off the grass.’ Then I would stomp all over it.” Heavily tranquilizing antipsychotic drugs (e.g. Zyprexa and Risperdal) are now the highest grossing class of medication in the United States ($16 billion in 2010); a major reason for this, according to the Journal of the American Medical Association in 2010, is that many children receiving antipsychotic drugs have nonpsychotic diagnoses such as ODD or some other disruptive disorder (this especially true of Medicaid-covered pediatric patients).

For some reason, I had foxes on my mind as well, and so I entered the word “Fox” into google; and I should have known that it’d provide lots of hits for the US TV conglomerate. One story that came up on the search had to do with a twitter account called @LIPartyStories. This was apparently a feed that would repost pictures sent from its teenage followers of themselves in various states of intoxication and déshabillé. So far, so straightforward: the day that teenagers stop getting drunk and doing stupid things at parties is the day that the world will stop turning. Granted, when I was young, we didn’t post stuff online – but if the internet had been around, we probably would have. Kids do daft stuff; they sometimes regret it; then they grow up, and do daft stuff less.

The Italian woman was sedated and her baby delivered against her will, after Essex social services obtained a court order in August 2012 for the birth “to be enforced by way of caesarean section”.

[…]

After the C-section, the woman, who has two other children and is divorced, was sent back to Italy without her daughter. She returned to Britain in February to request the return of her daughter, who is now 15 months old, but was told at Chelmsford Crown Court that she was to be put up for adoption in case her mother suffered a relapse.

UPDATE: Essex CC has a statement here. Thanks to Nathan Emmerich for the pointer via twitter.